Basic Information
| Provider Information | |||||||||
| NPI: | 1720489602 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAUCH | ||||||||
| FirstName: | MEGHAN | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BACIC | ||||||||
| OtherFirstName: | MEGHAN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2795 RICHMOND AVE | ||||||||
| Address2: | #2 | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103145866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187619800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2795 RICHMOND AVE | ||||||||
| Address2: | #2 | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103145866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187619800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2014 | ||||||||
| LastUpdateDate: | 11/24/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 44SL05841400 | NJ | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 0921821 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.